This past month JAMDA published an article by Clemency et al. titled “Decisions by Default: Incomplete or Contradictory MOLST in Emergency Care.” The article raised some known challenges with both MOLST completion, such as the frequency of “skipped” or deferred sections on the document, and errors or inconsistencies in MOLST completion, including incompatible orders. While we agree with Clemency et al. about the need for improved MOLST discussions and better MOLST completion, we also felt that there were some issues with the article that we addressed in a response, published this week by JAMDA, which we encourage you to read here. The authors of the original article also provided a response to our letter, which you can view here.

MOLST is a set of actionable medical orders, NOT an advance directive. In NY, physicians are accountable for medical orders that must be followed in an emergency. MOLST discussions conducted by a team MUST be done within scope of practice. Physicians, NOT social workers, nurses or chaplains, are responsible for medical orders. Thus, physicians are responsible for these medical errors.

Due to space limitations on our response we were not able to fully address all of the items that we believe are needed for a robust program dedicated to improving end-of-life care, including high-quality MOLST completion and system-wide eMOLST implementation. Critical items that we recommend health systems, nursing homes, and physician practices address include:

• Culture Change – both among professionals and community members.
• Professional training of physicians, clinicians and other professionals in advance care planning, end-of-life discussions, MOLST completion, complying with the legal-ethical process designed in NYS Public Health Law, and eMOLST utilization.
• Public advance care planning and MOLST education as well as engagement & empowerment of patients & families in these conversations and decisions.
• Thoughtful conversations with patients & families that use a standardized process for end-of-life discussions and thorough documentation.
• Shared, informed medical decision making that occurs between patients, families, physicians, and other trained health care professionals.
• Care planning to support MOLST decisions.
• System implementation of eMOLST, including establishing or revising policies & procedures, improving workflow, incorporating quality improvement activities and addressing IT integration needs.
• Dedicated system and physician champions who will make improving end-of-life care a priority and ensure these key dimensions are sustainably embedded in the culture of the health care system.
• Payment, including leveraging CPT codes 99497 & 99498 to encourage upstream conversations and shared, informed decision making using MOLST when appropriate.

Featured Resource: Advantages of eMOLST - A Nursing Home Physician's Perspective

Dr. Kim Petrone, a physician at St. Ann's Community in Rochester, NY, shares her perspectives on the advantages of eMOLST. Dr. Petrone is an early adopter of eMOLST and appreciates the person-centered approach, quality assurance, patient safety features and ease of use. She has contributed to enhancements made to eMOLST.

MOLST FAQ: How should MOLST be completed?

Completion of the MOLST follows the 8-Step Protocol. It begins with a conversation or a series of conversations between the patient, the health care agent or the surrogate, and a qualified, trained health care professional that defines the patient’s goals for care, reviews possible treatment options on the entire MOLST form, and ensures shared, informed medical decisionmaking. Review NYSDOH General Instructions and view Dr. Giokas using the 8-Step Protocol in this video.

eMOLST Champion: NYU Langone Medical Center

NYU Langone Medical Center, an academic medical center located in New York City, provides care to millions of New Yorkers each year. Since 2015 NYU Langone has been working on a special project to improve advance care planning processes, end-of-life conversations and accompanying documentation across their health system. Advance Care Planning and improving end of life care is a major initiative at NYU Langone championed by their Chief Nursing Officer, Dr. Kimberly Glassman, and their Chief Medical Officer, Dr. Fritz Francois. With a strong project committee in place led by, Tom Sedgwick, Senior Director of Social Work, Christine Wilkins, Advance Care Planning Program Manager, Dr. Jonathan Austrian, Medical Director of Inpatient Clinical Informatics, and Steven Chen, Medical Center Information Technology, they recognized that using the eMOLST system would be best practice for end-of-life conversations and the team began working on eMOLST implementation.

NYU Langone’s approach to eMOLST implementation has been marked by the strength of their overarching project committee, their empowered direct project team, and their commitment to excellence in ensuring the best experience for both providers and patients & families. As part of this, NYU Langone prioritized technical integration from their Epic EMR to eMOLST and enabled SSO + Patient Context for all of their users from day one. The first group of eMOLST users were officially loaded and launched in August 2016. The launch went smoothly as they had a strong team dedicated to the work and others available who were prepared to handle any issues.

NYU Langone is using a phased approach to implementation, as many organizations do, by starting with the palliative care team, geriatrics team, and then moving forward with other areas including medicine, ICUs, the Emergency Department, and the Cancer Center. Just six months in, more than 800 clinical professionals have access to eMOLST. The plan in the coming months is to expand eMOLST to the ambulatory sites, and NYU Lutheran Medical Center.

NYU Langone has also taken the time to train providers extensively on advance care planning and end-of-life conversations to ensure that patients and families have opportunities for more robust discussions than they had in the past. Coupled with the eMOLST system, this ensures that conversations and decisions are goals-based, patient-centered, and well-documented.

NYU Langone recognizes there is much more work to be done in this arena, but with the large scope of this project in general, and implementation of eMOLST in particular, they have again demonstrated their commitment to high quality, patient-centered care. We are looking forward to their continued success.

Top 10 Reasons to Use eMOLST

By Katie Orem, MPH, eMOLST Administrator

We sing the praises of eMOLST on a daily basis. Whether it is a provider calling with MOLST questions or hospital and nursing home administrators who want to make sure they’re following the right processes, eMOLST is the way to go. Here are the top ten reasons why your organization should be implementing eMOLST:

1. It’s the best way to capture and honor patients’ wishes at the end of life. Plus, our goals for care text box rocks, just ask Dr. Petrone.

2. Its logic-based coding prevents both common and serious errors, including incompatible orders.

3. It guarantees that you’ve completed all required documentation to ensure decisions are made ethically and comply with multiple public health laws.

4. It’s easy to use! eMOLST is based on a clinically logical workflow, it supports a team-based approach to these conversations, and it only asks required questions.

5. It keeps track of review and renew requirements and lets physicians easily confirm the discussion and sign the orders electronically.

6. You will never lose another MOLST form. The eMOLST form and accompanying documentation are always accessible. The form can be printed on pink paper if paper copies are needed.

7. It’s free! eMOLST is a public health service. We don’t charge licensing fees to access the eMOLST application.

8. It’s EMR agnostic – it doesn’t matter which EMR you use, or if you use one at all. eMOLST is web-based so it works with everything and it’s accessible everywhere you have internet access.

9. SAML-based Single Sign On (SSO) + Patient Context allows for single click search or retrieval of a patient's form without needing to enter a username & password or type the patient’s core demographics. Learn more about SSO + Patient Context in our integration guide.

10. eMOLST is a statewide and universally available public health solution for end-of-life care. It’s accessible in any care setting and the excellent documentation improves care transitions.

Systems that have already implemented eMOLST are recognizing these benefits and encouraging their partner organizations to also participate in using the eMOLST system. The more organizations that use eMOLST the better the value for everyone - from patients & families to professionals using the system.

We have seen that implementing eMOLST also presents an opportunity for organizations to take a thorough look at advance care planning processes in general, which often leads to identification of other areas for improvement including emphasizing the importance of health care proxy completion among employees and patients who are 18 and older.

Organizations that are interested in improving advance care planning practices and implementing eMOLST are welcome to read more about eMOLST at NYSeMOLSTregistry.com. We also recommend that project teams view our eMOLST webinar, hosted by IPRO, as a group.